Coroner's Finding: de-identified EK

MAGISTRATES COURT of TASMANIA

CORONIAL DIVISION Record of Investigation into Death (Without Inquest) Coroners Act 1995 Coroners Rules 2006 Rule 11 (These findings have been de-identified in relation to the name of the deceased, and family by direction of the Coroner pursuant to s57(1)(c) of the Coroners Act 1995 I, Olivia McTaggart, Coroner, having investigated the death of EK Find, pursuant to Section 28(1) of the Coroners Act 1995, that a) The identity of the deceased is EK, date of birth 15 January 1943.

b) EK was 80 years of age, married and lived in Lefroy. He was a farmer and generally in good health. On 11 April 2023, EK underwent an elective microdiscectomy in his lower spine (L4/5) at Calvary Hospital Lenah Valley to relieve severe spinal pain. The surgery was uneventful and he was discharged the following day.

Throughout June 2023, EK experienced ongoing severe pain in his back and other areas. His general practitioner also diagnosed him with a lower respiratory tract infection, after blood tests, and commenced him on antibiotics. He was also prescribed strong analgesia for his pain.

On or about 27 June 2023, EK was admitted to the George Town District Hospital after an abscess burst at the site of the spinal surgery wound. His condition had deteriorated and blood cultures were positive for staphylococcal aureus bacteria and he was commenced on intravenous antibiotics. On 30 June 2023 an MRI scan of the lumbar spine at the Launceston General Hospital showed post-operative discitis with an infection at the surgery site.

On 1 July 2023, EK was transferred to Calvary Hospital in Hobart where he was reviewed by the Infectious Diseases Team. There, his diagnosis was confirmed as staphylococcus aureus spinal infection post laminectomy. He remained an inpatient and fully treated for his infection. A wound washout procedure was planned. On 13 July 2023, the washout and debridement was performed.

However, EK developed septic shock and, post operatively, remained unstable.

On 27 July 2023, he developed hospital-acquired pneumonia. Despite ongoing

aggressive treatment in hospital, the infection could not be controlled. He developed sepsis, kidney failure and possibly endocarditis. Finally, on 5 August 2023, an MRI brain scan showed that he had suffered a large parietal area stroke.

In light of his poor prognosis, he was transitioned to palliative care. He passed away in hospital on 17 August 2023.

c) EK’s cause of death was haemorrhagic stroke caused by staphylococcus aureus sepsis due to his L 4/5 discectomy wound infection.

d) EK died on 17 August 2023 at Lenah Valley, Tasmania.

In making the above findings, I have had regard to the evidence gained in the investigation into EK’ death. The evidence includes:

• The Police Report of Death for the Coroner;

• Affidavits as to identity and life extinct;

• Opinion of the forensic pathologist regarding cause of death;

• Launceston General Hospital records;

• Calvary Hospital records; and

• Medical review by Dr Anthony Bell, Coronial Medical Consultant.

Comments and Recommendations I requested a medical case review in this matter from Dr Anthony Bell coronial medical consultant. 1 Dr Bell provided me with a very thorough report, in which he formed the view that there were no deficiencies in the treatment and care of EK from the time of his microdiscectomy until his death.

Relevantly, Dr Bell noted that the presentation of patients with a post-operative spine infection can vary significantly depending upon the type of infection. He noted that the most common symptom of infection is pain, which he described as “usually insidious in onset about one month post operatively”. He also outlined other issues which may cause a confusing clinical picture and delay diagnosis. He stated that, in this case, the detection of the post-operative infection was further complicated by the general practitioner’s (appropriate) prescription of antibiotics, which may have temporarily suppressed the spinal infection.

Dr Bell concluded that once EK’s infection had been correctly diagnosed, active and appropriate treatment occurred. However, the infection was severe (possibly with endocarditis) and could not be controlled.

1 MD FRACP FCICM

The circumstances of EK’s death are not such as to require me to make recommendations pursuant to Section 28 of the Coroners Act 1995.

I convey my sincere condolences to the family and loved ones of EK.

Dated: 4 November 2024 at Hobart, in the State of Tasmania.

Olivia McTaggart Coroner